Florida Regulations 65A-1.711: SSI-Related Medicaid Non-Financial Eligibility Criteria
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To qualify for Medicaid an individual must meet the general and categorical requirements in 42 C.F.R. part 435, subparts E and F (2007) (incorporated by reference), with the exception that individuals who are neither aged nor disabled may qualify for breast and cervical cancer treatment, and the following program specific requirements as appropriate. Individuals who are in Florida temporarily may be considered residents of the state on a case-by-case basis, if they indicate an intent to reside in Florida and can verify that they are residing in Florida.
(1) For MEDS-AD Demonstration Waiver, the individual must be age 65 or older, or disabled as defined in 20 C.F.R. § 416.905 (2007) (incorporated by reference).
(2) For ICP benefits, an individual must be:
(a) Living in a licensed nursing facility, or confined to a hospital swing bed or to a hospital-based skilled nursing facility bed, or in an ICF/DD facility that is certified as a Medicaid provider and provides the level of care that the client needs as determined by the Department; or living in a Florida state mental hospital and be age 65 or over; and,
(b) Determined to be in medical need of institutional care services according to Rules 59G-4.180 and 59G-4.290, F.A.C., for nursing facility, hospital swing bed placements and placements in a hospital-based skilled nursing facility bed according to Fl. Admin. Code Chapter 65B-38, for ICF/DD facilities or according to Fl. Admin. Code R. 59G-4.300, for state mental hospitals.
(c) If the individual is in a hospital swing bed or in a hospital-based skilled nursing facility bed, meet the requirements for length of stay prescribed in Fl. Admin. Code R. 59G-4.200
(3) To be eligible for the Hospice program, an individual must:
(a) Have a terminal illness and a written medical prognosis of six months or less to live if the illness runs its normal course, signed by the hospice medical director or physician member of the hospice interdisciplinary group, and the individual’s attending physician, if there is one;
(b) File an election of hospice care statement with the hospice provider as required in Fl. Admin. Code R. 59G-4.140;
(c) Be served by a qualified hospice provider as prescribed in Fl. Admin. Code R. 59G-4.140; and,
(d) Waive all rights to Medicaid services for the duration of the election of hospice care as specified in Fl. Admin. Code R. 59G-4.140
(4) To be eligible for a Home and Community Based Services Waiver program, an individual must meet the requirements of Fl. Admin. Code R. 59G-13.080 An individual cannot receive waiver coverage and institutional care program coverage at the same time. An individual residing in a nursing home may apply for the waiver, but the individual’s approval must be subject to their discharge and move into a community living arrangement. AHCA, in coordination with the program responsible for the daily operations of the waiver, requests the number of individuals to be served by the waiver as part of each waiver submission. The Centers for Medicare and Medicaid Services approve the request based on information provided by the state. Additionally, an individual must meet the criteria for one of the following waivers:
(a) Be at least 65 years of age and meet the requirements of subsection 65A-1.701(5), F.A.C., to participate in the Channeling waiver, or
(b) Be determined disabled in accordance with SSI disability criteria set forth in 42 C.F.R. §§435.540 (2007) and 435.541 (2007) (both incorporated by reference) and meet the requirements of subsection 65A-1.701(24), F.A.C., to participate in the Project AIDS Care waiver, or
(c) Be age 65 or older, or be 18 years of age through 64 years of age and disabled in accordance with SSI disability criteria set forth in 42 C.F.R. §§435.540 (2007) and 435.541 (2007) (both incorporated by reference), and meet the requirements of subsection 65A-1.701(1), F.A.C., to participate in the ADA/Home and Community Based Services waiver program, or
(d) Be disabled in accordance with SSI disability criteria set forth in 42 C.F.R. §§435.540 (2007) and 435.541 (2007) (both incorporated by reference) and meet the requirements of subsection 65A-1.701(10), F.A.C., to participate in the Developmental Services waiver program, or
(e) Be age 60 or older and meet the requirements in subsection 65A-1.701(3), F.A.C., to participate in the Assisted Living waiver, or
(f) Be age 18 through 64 and disabled in accordance with SSI disability criteria set forth in 42 CFR §§435.540 (2007) and 435.541 (2007) (both incorporated by reference) with a medical condition of traumatic brain injury or spinal cord injury in accordance with the Centers for Medicare and Medicaid Services approved Medicaid waiver.
(5) To be eligible as a QMB or for the SLMB coverage the individual must be entitled to Medicare.
(6) To be eligible for WD the individual must be entitled to enroll for Medicare Part A in accordance with Title XVIII, Section 1818A of the Social Security Act (42 U.S.C. § 1395i-2a, 2000 Ed., Sup. V, incorporated by reference).
(7) In addition, optional coverage is provided in accordance with Secs. 1920B and 1902(aa) of the Social Security Act (2007), incorporated by reference, as it pertains to breast and cervical cancer treatment. This coverage is provided only for the duration of the individual’s treatment. Applicants are referred by the Department of Health. A face to face interview is not required as a result of this referral. The application form for this coverage is CF-ES 2099, Medicaid Application for Breast and Cervical Cancer Treatment, July 2002 (incorporated by reference). Additional rights and responsibilities are explained to applicants on Your Rights and Responsibilities, CF-ES 2064, 03/2012, incorporated by reference in Fl. Admin. Code R. 65A-1.204; this form is provided to each applicant. A form requesting verification of the length of treatment, CF-ES 2701, Request for Length of Treatment Information, Dec. 2001 (incorporated by reference), along with a return envelope are given to the applicant to obtain the required verification from the provider. Alternatively, this information may be obtained by the Department through telephone contact with the provider, when known.
(8) Copies of the forms incorporated by reference in this rule may be obtained from the Department of Children and Families, Economic Self-Sufficiency Program Office, 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700.
Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.903, 409.904, 409.906, 409.919 FS. History-New 10-8-97, Amended 4-1-03, 8-10-06 (1), 8-10-06 (8), (9), 9-16-08.
(2) For ICP benefits, an individual must be:
(a) Living in a licensed nursing facility, or confined to a hospital swing bed or to a hospital-based skilled nursing facility bed, or in an ICF/DD facility that is certified as a Medicaid provider and provides the level of care that the client needs as determined by the Department; or living in a Florida state mental hospital and be age 65 or over; and,
(b) Determined to be in medical need of institutional care services according to Rules 59G-4.180 and 59G-4.290, F.A.C., for nursing facility, hospital swing bed placements and placements in a hospital-based skilled nursing facility bed according to Fl. Admin. Code Chapter 65B-38, for ICF/DD facilities or according to Fl. Admin. Code R. 59G-4.300, for state mental hospitals.
(c) If the individual is in a hospital swing bed or in a hospital-based skilled nursing facility bed, meet the requirements for length of stay prescribed in Fl. Admin. Code R. 59G-4.200
(3) To be eligible for the Hospice program, an individual must:
(a) Have a terminal illness and a written medical prognosis of six months or less to live if the illness runs its normal course, signed by the hospice medical director or physician member of the hospice interdisciplinary group, and the individual’s attending physician, if there is one;
(b) File an election of hospice care statement with the hospice provider as required in Fl. Admin. Code R. 59G-4.140;
(c) Be served by a qualified hospice provider as prescribed in Fl. Admin. Code R. 59G-4.140; and,
(d) Waive all rights to Medicaid services for the duration of the election of hospice care as specified in Fl. Admin. Code R. 59G-4.140
(4) To be eligible for a Home and Community Based Services Waiver program, an individual must meet the requirements of Fl. Admin. Code R. 59G-13.080 An individual cannot receive waiver coverage and institutional care program coverage at the same time. An individual residing in a nursing home may apply for the waiver, but the individual’s approval must be subject to their discharge and move into a community living arrangement. AHCA, in coordination with the program responsible for the daily operations of the waiver, requests the number of individuals to be served by the waiver as part of each waiver submission. The Centers for Medicare and Medicaid Services approve the request based on information provided by the state. Additionally, an individual must meet the criteria for one of the following waivers:
(a) Be at least 65 years of age and meet the requirements of subsection 65A-1.701(5), F.A.C., to participate in the Channeling waiver, or
(b) Be determined disabled in accordance with SSI disability criteria set forth in 42 C.F.R. §§435.540 (2007) and 435.541 (2007) (both incorporated by reference) and meet the requirements of subsection 65A-1.701(24), F.A.C., to participate in the Project AIDS Care waiver, or
(c) Be age 65 or older, or be 18 years of age through 64 years of age and disabled in accordance with SSI disability criteria set forth in 42 C.F.R. §§435.540 (2007) and 435.541 (2007) (both incorporated by reference), and meet the requirements of subsection 65A-1.701(1), F.A.C., to participate in the ADA/Home and Community Based Services waiver program, or
(d) Be disabled in accordance with SSI disability criteria set forth in 42 C.F.R. §§435.540 (2007) and 435.541 (2007) (both incorporated by reference) and meet the requirements of subsection 65A-1.701(10), F.A.C., to participate in the Developmental Services waiver program, or
(e) Be age 60 or older and meet the requirements in subsection 65A-1.701(3), F.A.C., to participate in the Assisted Living waiver, or
(f) Be age 18 through 64 and disabled in accordance with SSI disability criteria set forth in 42 CFR §§435.540 (2007) and 435.541 (2007) (both incorporated by reference) with a medical condition of traumatic brain injury or spinal cord injury in accordance with the Centers for Medicare and Medicaid Services approved Medicaid waiver.
(5) To be eligible as a QMB or for the SLMB coverage the individual must be entitled to Medicare.
(6) To be eligible for WD the individual must be entitled to enroll for Medicare Part A in accordance with Title XVIII, Section 1818A of the Social Security Act (42 U.S.C. § 1395i-2a, 2000 Ed., Sup. V, incorporated by reference).
(7) In addition, optional coverage is provided in accordance with Secs. 1920B and 1902(aa) of the Social Security Act (2007), incorporated by reference, as it pertains to breast and cervical cancer treatment. This coverage is provided only for the duration of the individual’s treatment. Applicants are referred by the Department of Health. A face to face interview is not required as a result of this referral. The application form for this coverage is CF-ES 2099, Medicaid Application for Breast and Cervical Cancer Treatment, July 2002 (incorporated by reference). Additional rights and responsibilities are explained to applicants on Your Rights and Responsibilities, CF-ES 2064, 03/2012, incorporated by reference in Fl. Admin. Code R. 65A-1.204; this form is provided to each applicant. A form requesting verification of the length of treatment, CF-ES 2701, Request for Length of Treatment Information, Dec. 2001 (incorporated by reference), along with a return envelope are given to the applicant to obtain the required verification from the provider. Alternatively, this information may be obtained by the Department through telephone contact with the provider, when known.
(8) Copies of the forms incorporated by reference in this rule may be obtained from the Department of Children and Families, Economic Self-Sufficiency Program Office, 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700.
Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.903, 409.904, 409.906, 409.919 FS. History-New 10-8-97, Amended 4-1-03, 8-10-06 (1), 8-10-06 (8), (9), 9-16-08.